Beck, Depression

8/6/2019 Beck, Depression

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Thinkingand

Depression/. Idiosyncratic Content and

Cognitive Distortions

AARON T. BECK, MD

PHILADELPHIA

The clinical and theoretical papers dealing with the psychological correlates of depression have predominantly utilized amotivational-affective model for categorizingand interpreting the verbal behavior of the

patients. The cognitive processes as suchhave received little attention except insofaras they were related to variables such as hostility, orality, or guilt.1

The relative lack of emphasis on thethought processes in depression may be areflection ofor possibly a contributing factor tothe widely held view that depressionis an affective disorder, pure and simple, andthat any impairment of thinking is the result of the affective disturbance.2 This opinion has been buttressed by the failure todemonstrate any consistent evidence of abnormalities in the formal thought processesin the responses to the standard battery ofpsychological tests.3 Furthermore, the fewexperimental studies of thinking in depression have revealed no consistent deviationsother than a retardation in the responses to"speed tests" * and a lowered

responsivenessto a Gestalt Completion Test.5In his book on depression, Kraines on

the basis of clinical observations indicatedseveral characteristics of a thought disorderin depression. The objective of the presentstudy has been to determine the prevalenceof a thought disorder among depressed patients in psychotherapy and to delineate itscharacteristics. An important corollary ofthis

objective has been the specification ofthe differences from and the similarities tothe thinking of nondepressed psychiatric patients. This paper will focus particularly onthe following areas: (1) the idiosyncraticthought content indicative of distorted orunrealistic conceptualizations; (2) the processes involved in the deviations from logicalor realistic thinking; (3) the formal characteristics of the ideation showing such

Submitted for publication May 6, 1963.From the Department of Psychiatry, University

of Pennsylvania School of Medicine.This investigation was supported in part by Re

search Grant M3358 from the National Institute ofMental Health.

on March 23, 2011www.archgenpsychiatry.comDownloaded from
http://www.archgenpsychiatry.com/http://www.archgenpsychiatry.com/http://www.archgenpsychiatry.com/http://www.archgenpsychiatry.com/


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deviations; (4) the relation between the cognitive distortions and the affects characteristic of depression.

Clinical Material

The data for this study were accumulatedfrom interviews with 50 psychiatric patientsseen by the author in psychotherapy orformal psychoanalysis. Of the patients, fourwere hospitalized for varying periods oftime during the treatment. The rest of thepatients were seen on an ambulatory basisthroughout their treatment.

The frequency of interviews varied fromone to six a week with the median number

of interviews three a week. The total lengthof time in psychotherapy ranged from sixmonths to six years; the median was two

years. In no case did a single episode ofdepression last longer than a year. A largeproportion of the patients continued in psychotherapy for a substantial period of timeafter the remission of their initial depressiveepisode. Thirteen patients either had recurrent depressions while in psychotherapy orreturned to psychotherapy because of a recurrence. In this recurrent depression group,six had completely asymptomatic intervalsbetween the recurrences and seven had some

degree of hypomanic elevation. It was, therefore, possible to obtain data from these patients during each phase of the cycle.Of the 50 patients in the sample, 16 were

men and 34 were women. The age rangewas from 18 to 48 with a median of 34.An estimate of their intelligence suggestedthat they were all of at least bright averageintelligence. The socioeconomic status of thepatients was judged to be middle or upperclass. Twelve of the patients were diagnosedas psychotic depressive or manic-depressivereactions and 38 as neurotic depressive reactions. (A study based on six of the patientsin this group has already been published.7)

In establishing the diagnosis of depression the following diagnostic indicatorswere employed: (a) objective signs of depression in the facies, speech, posture, andmotor activity; (b) a major complaint offeeling depressed or sad and at least 11 of

the following 14 signs and symptoms : lossof appetite, weight loss, sleep disturbance,loss of libido, fatiguability, crying, pessimism, suicidal wishes, indecisiveness, lossof sense of humor, sense of boredom or

apathy,overconcern about

health,excessive

self-criticisms, and loss of initiative.Patients showing evidence of organic

brain damage or of a schizophrenic processand cases in which anxiety or some otherpsychopathological state was more prominent than depression were excluded fromthis group.In addition to the group of depressed pa

tients, a group of 31 nondepressed patientswere

also seen in psychotherapy. The composition of this group was similar to the depressed group in respect to age, sex, andsocial position. These patients constituted a"control group" for this study.

Procedure

Face-to-face interviews were conductedduring the periods of time when the depressions were

regardedas moderate to severe

in intensity. The author was active and supportive during these periods. Formal analysis was employed for the long-term patientsexcept when they appeared to be seriouslydepressed; the couch was utilized, free association was encouraged, and the psychiatrist followed the policy of minimal activity.The recorded data used as the basis for thispaper were handwritten notes made by theauthor

duringthe

psychotherapeutic interviews. These data included retrospectivereports by the patients of feelings andthoughts prior to the sessions as well asspontaneous reports of their feelings andthoughts during the sessions. In addition,several patients regularly kept notes of theirfeelings and thoughts between psychotherapeutic sessions and reported these to thepsychiatrist.

During the period in which these datawere collected handwritten records of theverbalizations of the nondepressed patientswere made. These notes were used for purposes of comparison with the verbal reportsof the depressed group.



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FindingsIt was found that each of the depressed

patients differed from the patients in thenondepressed groups in the preponderanceof certain themes, which will be outlinedbelow.

Moreover,each of

the othernoso-

logical groups showed an idiosyncratic idea-tional content which distinguished themfrom each other as well as from the de

pressed group. The typical ideational contentof the depressed patients was characterizedby themes of low self-esteem, self-blame,overwhelming responsibilities, and desires toescape; of the anxiety states by themes ofpersonal danger; of the hypomanic states by

themes of self-enhancement; and of the hostile paranoid states by themes of accusationsagainst others.

Although each nosological group showedparticular types of thought content specificfor that group, the formal characteristicsand processes of distortion involved in the

idiosyncratic ideation were similar for eachof these nosological categories. The processes of distortion and the formal character

istics will be described in later sections ofthe paper.

Thematic Content of CognitionsThe types of cognitions * outlined below

were reported by the depressed patients tooccur under two general conditions. First,the typical depressive cognitions were observed in response to particular kinds of ex

ternal "stimulus situations." Thesewere

situations which contained an ingredient, orcombination of ingredients, whose contenthad some relevance to the content of the

idiosyncratic response. This stereotyped response was frequently completely irrelevantand inappropriate to the situation as a whole.For instance, any experience which touchedin any way on the subject of the patient'spersonal attributes might immediately make

him think he was inadequate.

A young man would respond with self-derogatory thoughts to any interpersonalsituation in which another person appearedindifferent to him. If a passerby on thestreet did not smile at him, he was proneto think he was inferior. Similarly, a womanconsistently had the thought she was a badmother whenever she saw another womanwith a child.

Secondly, the typical depressive thoughtswere observed in the patients' ruminationsor "free associations," ie, when they werenot reacting to an immediate external stimulus and were not attempting to direct theirthoughts. The severely depressed patients

often experienced long, uninterrupted sequences of depressive associations, completely independently of the external situation.Low Self-Regard.The low self-evalua

tions formed a very prominent part of thedepressed patients' ideation. This generallyconsisted of an unrealistic downgrading ofthemselves in areas that were of particularimportance to them. A brilliant academicianquestioned his basic intelligence, an attrac

tive society woman insisted she had becomerepulsive-looking, and a successful businessman began to believe he had no real businessacumen and was headed for bankruptcy.

The low self-appraisal was applied to personal attributes, such as ability, virtue, attractiveness, and health; acquisitions oftangibles or intangibles (such as love orfriendship) ; or past performance in one'scareer or role as a spouse or parent. In

making these self-appraisals the depressedpatient was prone to magnify any failuresor defects and to minimize or ignore anyfavorable characteristics.

A very common feature of the self-evaluations was the comparison with otherpeople, particularly those in his own socialor occupational group. Almost uniformly,in making his comparisons, the depressed

patient tendedto

rate himself as inferior.He regarded himself as less intelligent, lessproductive, less attractive, less financiallysecure, or less successful as a spouse or

parent than those in his comparison group.These types of self-ratings comprise the

* The term cognition is used in the present treatment to refer to a specific thought, such as an interpretation, a self-command, or a self-criticism.The term is also applied to wishes (such as suicidaldesires) which have a verbal content.



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"feeling of inferiority," which have beennoted in the literature on depressives.

Ideas of Deprivation.Allied to the low

self-appraisals are the ideas of destitutionthat were seen in certain depressed patients.These ideas were noted in the patient's verbalized thoughts that he was alone, unwanted, and unlovable, often in the face ofovert demonstrations of friendship and affection from other people. The sense of

deprivation was also applied to material possessions, despite obvious evidence to the contrary.

Self-Criticisms and Self-Blame.Anotherprominent theme in the reported thoughtsof the

depressed patientswas concerned

with self-criticisms and self-condemnations.These themes should be differentiated fromthe low self-evaluations described in the previous section. While the low self-evaluationrefers simply to the appraisal of themselvesrelative to their comparison group or theirown standards, the self-criticisms representsthe reproaches they leveled against themselves for their perceived shortcomings. It

should be pointed out, however, that not allpatients with low self-evaluations showedself-criticisms.

It was noteworthy that the self-criticisms,just as the low self-evaluations, were appliedto those specific attributes or behaviorswhich were highly valued by the individual.A depressed woman, for example, condemned herself for not having breakfastready for her husband. On another occa

sion, however, she reported a sexual affairwith one of his colleagues without any evidence of regret, self-criticism, or guilt:Competence as a housewife was one of herexpectations of herself whereas marital fidelity was not.

The patients' tendency to blame themselves for their mistakes or shortcomingsgenerally had no logical basis. This wasdemonstrated

bya housewife who

tookher

children on a picnic. When a thunderstormsuddenly appeared she blamed herself fornot having picked a better day.

Overwhelming Problems and Duties.The patients consistently magnified the

magnitude of problems or responsibilitiesthat they would consider minor or insignificant when not depressed.A depressed housewife, when confronted

with the necessity of sewing "name tags" onher children's clothes in

preparationfor

camp, perceived this as a gigantic undertaking which would take weeks to complete.When she finally did get to work at it, shewas able to finish the task in less than a day.

Self-Commands and Injunctions.Self-coercive cognitions, while not prominentlymentioned in the literature on depression,appeared to form a substantial proportion ofthe verbalized thoughts of the patients in the

sample. These cognitions consisted of constant "nagging" or prodding to do particular things. The prodding would persist eventhough it was impractical, undesirable, orimpossible for the person to implement theseself-instructions.

In a number of cases, the "shoulds" and"musts" were applied to an enormous rangeof activities, many of which were mutuallyexclusive. A housewife reported that in a

period of a few minutes, she had compellingthoughts to clean the house, lose someweight, visit a sick friend, be a "DenMother," get a full-time job, plan the week'smenu, return to college for a degree, spendmore time with her children, take a memorycourse, to be more active in women's organizations, and start putting away her family'swinter clothes.

Escape and Suicidal Wishes.Thoughtsabout escaping from the problems of lifewere frequent among all the patients. Somehad daydreams of being a hobo or going toa tropical paradise. It was unusual, however,that evading the tasks brought any relief.Even when a temporary respite was takenon the advice of the psychiatrist, the patients were prone to blame themselves for

"shirking responsibilities."

The desire to escape seemed to be relatedto the patients' viewing themselves at an impasse. On the one hand, they saw themselvesas incapable, incompetent, and helpless. Onthe other hand they saw their tasks as ponderous and formidable. Their response was



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a wish to withdraw from the "unsolvable"

problems. Several patients spent considerable time in bed; some hid under the covers.

The suicidal preoccupations similarlyseemed related to the patient's conceptualization of his situation as untenable or hopeless. He believed he could not tolerate acontinuation of his suffering and he couldsee no solution to the problem: The psychiatrist could not help him, his symptoms couldnot be alleviated, and his various problemscould not be solved. The suicidal patientsgenerally stated that they regarded suicideas the only possible solution for their "desperate" or "hopeless" situation.

Typology of Cognitive Distortions

The preceding section attempted to delineate the typical thematic content of the verbalizations of the depressed patients. Acrucial characteristic of the cognitions withthis content was that they represented varying degrees of distortion of reality. Whilesome degree of inaccuracy and inconsistencywould be expected in the cognitions of anyindividual, the distinguishing characteristicof the depressed patients was that theyshowed a systematic error; viz, a bias againstthemselves. Systematic errors were alsonoted in the idiosyncratic ideation of theother nosological groups.

The typical depressive cognitions can becategorized according to the ways in which

theydeviate from

logicalor realistic think

ing. The processes may be classified asparalogical (arbitrary inference, selectiveabstraction, and over-generalization), stylistic (exaggeration), or semantic (inexact labeling). These cognitive distortions wereobserved at all levels of depression, fromthe mild neurotic depression to the severepsychotic. While the thinking disorder wasobvious in the psychotic depressions, it was

observable inmore

subtle ways among allthe neurotic depressed.Arbitrary interpretation is defined as the

process of forming an interpretation of asituation, event, or experience when there isno factual evidence to support the conclusion

or when the conclusion is contrary to theevidence.

A patient riding on the elevator had thethought, "He (the elevator operator) thinksI'm a nobody." The patient then felt sad.On being questioned by the psychiatrist, herealized there was no factual basis for his

thought.Such misconstructions are particularly

prone to occur when the cues are ambiguous.An intern, for example, became quite discouraged when he received an announcement that all patients "worked-up" by theinterns should be examined subsequently bythe resident

physicians.His

thoughton

reading the announcement was, "The chiefdoesn't have faith in my work." In this in

stance, he personalized the event althoughthere was no ostensible reason to suspect thathis particular performance had anything todo with the policy decision.Intrinsic to this type of thinking is the

lack of consideration of the alternative ex

planations that are more plausible and more

probable. The intern, when questionedabout other possible explanations for thepolicy decision, then recalled a previousstatement by his "chief" to the effect thathe wanted the residents to have more contact with the patients, as part of their training. The idea that this explicitly statedobjective was the basis for the new policyhad not previously occurred to him.

Selective abstraction refers to the processof focusing on a detail taken out of context,ignoring other more salient features of thesituation, and conceptualizing the whole experience on the basis of this element.A patient, in reviewing her secretarial

work with her employer, was praised abouta number of aspects of her work. The employer at one point asked her to discontinuemaking extra carbon copies of his letters.

Her immediate thought was, "He is dissatisfied with my work." This idea became paramount despite all the positive statements hehad made.

Overgeneralization was manifested by thepatients' pattern of drawing a general con-



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elusion about their ability, performance, orworth on the basis of a single incident.A patient reported the following sequence

of events which occurred within a period ofhalf an hour before he left the house : His

wife was upset because the children wereslow in getting dressed. He thought, "I'ma poor father because the children are notbetter disciplined." He then noticed a faucetwas leaky and thought this showed he wasalso a poor husband. While driving to work,he thought, "I must be a poor driver or othercars would not be passing me." As he arrived at work he noticed some other personnel had

alreadyarrived. He

thought,"I

can't be very dedicated or I would have comeearlier." When he noticed folders and papers piled up on his desk, he concluded, "I'ma poor organizer because I have so muchwork to do."

Magnification and minimization refer toerrors in evaluation which are so gross asto constitute distortions. As described in thesection on thematic content, these processes

were manifested by underestimation of theindividual's performance, achievement orability, and inflation of the magnitude of hisproblems and tasks. Other examples werethe exaggeration of the intensity or significance of a traumatic event. It was fre

quently observed that the patients' initialreaction to an unpleasant event was to regardit as a catastrophe. It was generally foundon further inquiry that the perceived disasterwas often a relatively minor problem.A man reported that he had been upset

because of damage to his house as the resultof a storm. When he first discovered the

damage, his sequence of thoughts were, "Theside of the house is wrecked. ... It will costa fortune to fix it." His immediate reactionwas that his repair bill would be severalthousand dollars. After the initial shock had

dissipated,he realized that the

damagewas

minor and that the repairs would costaround $50.Often inexact labeling seems to contribute

to this kind of distortion. The affective reaction is proportional to the descriptive la-

beling of the event rather than to the actualintensity of a traumatic situation.A man reported during his therapy hour

that he was very upset because he had been"clobbered" by his superior. On further reflection, he realized that he had

magnifiedthe

incident and that a more adequate description was that his supervisor "corrected anerror" he had made. After re-evaluating theevent, he felt better. He also realized thatwhenever he was corrected or criticized by aperson in authority he was prone to describe this as being "clobbered."

Formal Characteristics of Depressive

CognitionsThe previous sections have attempted tocategorize the typical thematic contents ofthe verbalized thoughts of depressed patientsand to present observations regarding theprocesses involved in the conceptual errorsand distortions.

The inaccurate conceptualizations with depressive content have been labeled "depressive cognitions." This section will present asummary of the specific formal characteristics of the depressive cognitions as reportedby the patients.

One of the striking features of the typicaldepressive cognitions is that they generallywere experienced by the patients as arisingas though they were automatic responses, ie,without any apparent antecedent reflectionor reasoning.A

patient,for

example,observed that

when he was in a situation in which somebody else was receiving praise, he would"automatically" have the thought, "I'm nobody . . . I'm not good enough." Later,when he reflected on his response, he wouldthen regard it as inappropriate. Nonetheless, his immediate responses to such situations continued to be a self-devaluation.

The depressive thoughts not only ap

peared to be "automatic," in the sense justdescribed, but they seemed, also, to have aninvoluntary quality. The patients frequentlyreported that these thoughts would occureven when they had resolved "not to havethem" or were actively trying to avoid them.



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This involuntary characteristic was clearlyexemplified by repetitive thoughts of suicidalcontent but was found in a less dramatic

way in other types of depressive cognitions.A number of the patients were able to antici

patethe kind of

depressive thoughtsthat

would occur in certain specific situations andwould prepare themselves in advance to

make a more realistic judgment of the situation. Nevertheless, despite the intention toward off or control these thoughts, theywould continue to pre-empt a more rational

response.fAnother characteristic of the depressive

thoughtsis their

plausibilityto the

patient.At the beginning of therapy the patientstended to accept the validity of the cognitions uncritically. It often required considerable experience in observing thesethoughts and attempting to judge them rationally for the patients to recognize themas distortions. It was noted that the more

plausible the cognitions seemed (or the moreuncritically the patient regarded them), the

stronger the affective reaction.It was

alsoobserved that when the patient was able toquestion the validity of the thoughts, theaffective reaction was generally reduced.The converse of this also appeared to betrue: When the affective reaction to a

thought was particularly strong, its plausibility became enhanced and the patient foundit more difficult to appraise its validity. Furthermore, once a strong affect was aroused

in response to a distorted cognition, anysubsequent distortions seemed to have an increased plausibility. This characteristic appeared to be present irrespective of whetherthe affect was sadness, anger, anxiety, oreuphoria. Once the affective response was

dissipated, however, the patient could thenappraise these cognitions critically and recognize the distortions.A final characteristic of the depressive

cognitions was their perseveration. Despitethe

multiplicityand

complexityof life situ

ations, the depressed patient was prone tointerpret a wide range of his experiences interms of a few stereotyped ideas. The sametype of cognition would be elicited by highlyheterogeneous experiences. In addition,these idiosyncratic cognitions tended to occur repetitively in the patients' ruminationsand stream of associations.

Relation of Depressive Thoughts toAffectsAs part of the psychotherapy, the author

encouraged the patients to attempt to specifyas precisely as possible their feelings and thethoughts they had in relation to these feelings.A number of problems were presented in

the attempt to obtain precise description andlabeling of the feelings. The patients hadno difficulty in designating their feelings aspleasant or unpleasant. In the unpleasantgroup of affects they were readily able tospecify whether they felt depressed (or sad),anxious, angry, and embarrassed. Whenthey were asked to discriminate furtheramong the depressed feelings, there was considerable variability in the group. Most ofthe patients were able to differentiate with areasonable

degreeof

certaintyamong the

following feelings : sad, discouraged, hurt,humiliated, guilty, empty, and lonely.In attempting to determine the relation

of specific feelings to a specific thought, thepatients developed the routine of trying tofocus their attention on their thoughts whenever they had an unpleasant feeling or whenthe feeling became intensified. This oftenmeant "thinking back" after they were aware

of the unpleasant feeling to recall thecon

tent of the preceding thought. They frequently observed that an unpleasant thoughtpreceded the unpleasant affect.

The most noteworthy finding was thatwhen the thoughts associated with the de-

t The foregoing features may suggest that thedepressive thoughts are essentially a type of obsessional thinking. The depressive thoughts, however,differ from classical obsessional thinking in that

their specific content varies according to the particular stimulus situation and also in that they areassociated with an affective response. Obsessional

thoughts, on the other hand, tend to retain essentiallythe same "wording" with each repetition are generally regarded by the patient as a "strange" or"alien" idea, and are not associated with any feeling.



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pressive affects were identified they weregenerally found to contain the type of conceptual distortions or errors already described as well as the typical depressivethematic content. Similarly, when the affect was

anxiety,anger, or elation, the as

sociated cognitions had a content congruentwith these feelings.An attempt was made to classify the cog

nitions to determine whether there were anyspecific features that could distinguishamong the types of cognitions associated respectively with depression, anger, or elation.It was found, as might be expected, that thetypical thoughts associated with the depres

sive affect centered around the ideas thatthe individual was deficient in some sort of

way. Furthermore, the specific types of depressive affect were generally consistentwith the specific thought content. Thus,thoughts of being deserted, inferior, orderelict in some way, were associated re

spectively with feelings of loneliness, humiliation, or guilt.In the nondepressed group, the thoughts

associated with the affect of anxiety had thetheme of anticipation of some unpleasantevent. Thoughts associated with anger hadan element of blame directed against someother person or agency. Finally, feelings ofeuphoria were associated with thoughts thatwere self-inflating in some way.

Comment

It has been noted that "the

schizophrenicexcels in his tendency to misconstrue theworld that is presented.

. .

." 8 While the

validity of this statement has been supportedby numerous clinical and experimental studies, it has not generally been acknowledgedthat misconstructions of reality may also bea characteristic feature of other psychiatricdisorders. The present study indicates that,even in mild phases of depression, sys

tematic deviations from realisticand

logicalthinking occur. A crucial feature of thesecognitive distortions is that they consistentlyappeared only in the ideational material thathad a typically depressive content; for example, themes of being deficient in some

way. The other ideational material reportedby the depressed patients did not show anysystematic errors.

The thinking-disorder typology outlinedin this paper is similar to that described instudies of

schizophrenia.While some of the

most flagrant schizophrenic signs (such asword-salad, metaphorical speech, neologisms, and condensations) were not observed, the kinds of paralogical processes inthe depressed patients resembled those described in schizophrenics.8 Moreover, thesame kind of paralogical thinking was observed in the nondepressed patients in thecontrol group.

While each nosological category showed adistinctive thought content, the differencesin terms of the processes involved in thedeviant thinking appeared to be quantitativerather than qualitative. These findings suggest that a thinking disorder may be commonto all types of psychopathology. By applying this concept to psychiatric classification,it would be possible to characterize the specific nosological categories in terms of the

degree of cognitive impairment and the particular content of the idiosyncratic cognitions.

The failure of various psychological teststo reflect a thinking disorder in depression 3'45 warrants consideration. It may be

suggested that the particular tests employedmay not have been adequately designed forthe purpose of detecting the thinking deviations in

depression.Since clinical observa

tion indicates that the typical cognitivedistortions in depression are limited tospecific content areas (such as self-devaluations), the various object-sorting, proverb-interpreting, and projective tests may havemissed the essential pathology. It may benoted that even in studies of schizophrenia,the demonstration of a thinking disorder isdependent on the type of test administered

and the characteristics of the experimentalgroup. Cohen et al,5 for example, found thatthe only instrument eliciting abnormal responses in acute schizophrenics was theRorschach test whereas chronic schizo

phrenics showed abnormalities on a Gestalt



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Completion test as well as on the Rorschach.The clinical finding of a thinking disor

der at all levels of depression should focusattention on the problem of defining the precise relationship of the cognitive distortionsto the characteristic affective state in

depression. The diagnostic manual of the American Psychiatric Association (APA)2 definesthe psychotic affective reactions in terms of"a primary, severe disorder of mood withresultant disturbance of thought and behavior, in consonance with the affect." Al

though this is a widely accepted concept, theconverse would appear to be at least as plausible; viz, that there is primary disorder of

thought with resultant disturbance of affectand behavior in consonance with the cognitive distortions. This latter thesis is con

sistent with the conception that the way anindividual structures an experience determines his affective response to it. If, for

example, he perceives a situation as dangerous, he may be expected to respond witha consonant affect, such as anxiety.It is proposed, therefore, that the typical

depressive affects are evoked by the erroneous conceptualizations: If the patient incorrectly perceives himself as inadequate,deserted or sinful, he will experience corresponding affects such as sadness, loneliness, or guilt. On the other hand, thepossibility that the evoked affect may, inturn, influence the thinking should be considered. It is conceivable that once a de

pressive affect has been aroused, it willfacilitate the emergence of further depressive-type cognitions. A continuous interaction between cognition and affect may,consequently, be produced and, thus, lead tothe typical downward spiral observed in depression. Since it seems likely that thisinteraction would be highly complex, appropriately designed experiments would be warranted to clarify the relationships.A

thorough exposition of the theoreticalsignificance of the clinical findings is beyond the scope of this paper. It may betentatively suggested that in depression thereis a significant rearrangement of the cognitive organization. This modified organiza-

tion channels a large proportion of thethinking in the direction of negative self-evaluations, nihilistic predictions, and plansfor escape or suicide. It is postulated thatthis particular shift in the thought contentresults

specificallyfrom the activation and

dominance of certain idiosyncratic cognitivepatterns (schmas), which have a contentcorresponding to the typical depressivethemes in the verbal material. To the extent that these idiosyncratic schmas supersede more appropriate schmas in theordering, differentiation, and analysis of experience, the resulting conceptualizations ofreality will be distorted. A more complete

formulation of the cognitive organization indepression has been presented in anotherpaper.9

Before this discussion is concluded, a fewmethodological problems should be mentioned. A question could be raised, for example, regarding the generalizability of theobservations. Since the sample consistedlargely of psychotherapy patients of a relatively narrow range of intelligence andsocial index, there may be some uncertaintyas to whether the findings are applicable tothe general population of depressed patients.A previous study by the author and his co-investigators is pertinent to this question.An inventory was derived from the verbalized self-appraisals of the depressed patients included in the present study. Asystematic study of the responses to this instrument by a much larger and more

heterogeneous clinic and hospitalized sampledemonstrated that the self-reports of thepsychotherapy group were representative ofthe much broader group.10In view of the obvious methodological

problems associated with using data fromhandwritten notes of psychotherapy sessions, it is apparent that the findings of thepresent study will have to be subjected to

verification bymore

refined and systematicstudies. One promising approach has beendeveloped by Gottschalk et al n who utilizedverbatim recordings of five-minute periodsof free association by depressed patients andsubjected this material to blind scoring by



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trained judges. Such a procedure circumvents the hazards of therapist bias and suggestion associated with verbal materialrecorded in psychotherapy interviews.

Summaryand Conclusions

A group of 50 depressed patients inpsychotherapy and a control group of 31nondepressed patients were studied to determine the prevalence and types of cognitiveabnormalities. Evidence of deviation from

logical and realistic thinking was found atevery level of depression from mild neuroticto severe psychotic.

The ideation of the depressed patients dif

fered from that of the nondepressed in theprominence of certain typical themes; viz,low self-evaluation, ideas of deprivation, exaggeration of problems and difficulties, self-criticisms and self-commands, and wishes toescape or die. Similarly, each of the non-depressed nosological groups could be differentiated on the basis of their idiosyncraticthought content.

Abnormalities were detected consistentlyonly in those verbalized thoughts that hadthe typical thematic content of the depressedgroups. The other kinds of ideation did notshow any consistent distortion. Among thedeviations in thinking, the following processes were identified: arbitrary inference,selective abstraction, over-generalization,and magnification and minimization.

Since paralogical processes were also observed in the

idiosyncraticideation of non-

depressed patients, it was suggested that athought disorder may be common to all typesof psychopathology. The thesis was advanced that the various nosological groupscould be classified on the basis of the degreeof cognitive distortion and the characteristiccontent of their verbalized thoughts.In view of the observation that the dis

torted ideas of the depressed patients ap

peared immediately before the arousal orintensification of the typical depressive affects, it was suggested that the affective dis-

turbance may be secondary to the thinkingdisorder. The possibility of a reciprocal interaction between cognition and affect wasalso raised.

The thesis was advanced that the cognitivedistortions in

depressionresult from the

progressive dominance of the thoughtprocesses by idiosyncratic schmas. By superseding more appropriate schmas, theidiosyncratic schmas force the conceptualization of experience into certain rigid patterns with the consequent sacrifice ofrealistic and logical qualities.

Aaron T. Beck, MD, 133 S 36th St, Philadelphia4, Pa.

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5. Cohen, B. ; Senf, R. ; and Huston, P. : Perceptual Accuracy in Schizophrenia, Depression, andNeurosis and Effects of Amytal, J Abnorm SocPsychol 52:363, 1956.

6. Kraines, S. H. : Mental Depressions and TheirTreatment, New York: The Macmillan Company,1957.

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Schkophrenia, Berkeley and Los Angeles : University of California Press, 1944.

9. Beck, A. T. : Thinking and Depression : 2. ATheoretical Exploration, Mimeographed Paper,1963.

10. Beck, A. T.; Ward, C H. ; Mendelson, M. ;Mock, J. ; and Erbaugh, J. : An Inventory forMeasuring Depression, Arch Gen Psychiat 4:561,1961.

11. Gottschalk, L. ; Glesser, G. ; and Springer,K. : Three Hostility Scales Applicable to VerbalSamples, to be published, 1963.


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